Societies revise cardiac radionuclide imaging appropriateness criteria

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The Appropirate Use Criteria (AUC) task force has released the AUC for Cardiac Radionuclide Imaging, which refines appropriate use of pharmacologic tests compared with exercise stress tests and updates recommendations regarding radionuclide imaging (RNI) in the perioperative setting.

The ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging is a report from the American College of Cardiology Foundation (ACCF) AUC Task Force, the American Society of Nuclear Cardiology (ASNC), the American College of Radiology (ACR), the American Heart Association (AHA), the American Society of Echocardiography (ASE), the Society of Cardiovascular CT (SCCT), the Society for Cardiovascular Magnetic Resonance (SCMR) and SNM. It was published online May 18 in the Journal of the American College of Cardiology.

A panel of experts was queried regarding the appropriate use of RNI in 67 clinical situations, each of which was ranked one through nine, representing least to most appropriate and then grouped as inappropriate (one-three), uncertain (four-six) or appropriate (seven-nine). Overall, 33 indications were considered appropriate, nine uncertain and 25 inappropriate.

For patients presenting with "ischemic equivalent chest-pain syndrome," RNI was considered an appropriate test in the presence of possible acute coronary syndrome (ACS), but inappropriate in the presence of definite ACS. For patients with chronic ischemic equivalent pain, RNI was considered appropriate for those with an intermediate/high pretest probability of CAD, and in those with a low pretest likelihood and an uninterpretable electrocardiogram (ECG), but inappropriate in those with an interpretable ECG and able to exercise.

For asymptomatic patients, RNI was considered inappropriate in those with a low coronary heart disease (CHD) risk (Framingham: Adult Treatment Panel 3) and appropriate for those with a high CHD risk. For those with an intermediate CHD risk, RNI was considered inappropriate if the ECG was interpretable, and uncertain if uninterpretable.

For perioperative evaluation, RNI was considered inappropriate for patients undergoing low-risk surgery or in intermediate-risk surgery with no risk factors and good functional capacity. RNI was considered appropriate for intermediate risk or vascular surgery in the presence of one or more risk factors and poor functional capacity.

Following revascularization, RNI was considered appropriate in symptomatic patients as well as in those with incomplete revascularization. In asymptomatic patients, RNI was considered inappropriate when performed more than two years after PCI, but appropriate more than five years post-CABG.